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A PATIENT PRESENTS WITH TOOTHACHE IN THE UPPER LEFT SIDE OF
THE
MOUTH. DISCUSS YOUR ASSESSMENT AND STEPS NECESSARY TO ARRIVE
AT THE CORRECT DIAGNOSIS. WHAT IS THE POSSIBLE AETIOLOGY?
In the couple of years I have trained, I have come to realize
how easy it is for one to over-
enthusiascally hone in on one parcular diagnosis as the paent
relates his inial complaint. With
that respect, it is necessary to start the paent assessment with
open quesons to prevent
precluding the actual diagnosis or diagnoses. This allows the
paent to give a broader scope and
formulate the complaint with his words. Open quesons include
sentences such as:
How may I help you?
How are you?
Once the paent has given their complaint (which is the toothache
in the upper le side of the
mouth) I would then ask the paent to describe the pain rstly
with his own words and then I wouldgo through a detailed pain
history. Informaon that would be useful in the pain history
are:
Character of the pain Locaon Is it localised or diuse? Does it
travel anywhere around the face(Radiaon) Is there a parcular tooth
that is the source of the pain? Severity: the use of a pain scale
could be useful however it is extremely subjecve and
relave to the paents tolerance of pain
Duraon of the pain Frequency of the pain Exacerbang factors e.g.
hot, cold, sweet foods Precipitang factors e.g. when bing, on
release of bing or spontaneous Relieving factors e.g. use of
analgesia, pressure, eang on the other side
As I am taking the history, it is also worth visually inspecng
the body language of the paent. If the
paent is in severe pain, he may be holding the side of the face
that is painful. I would also ask if
there are further complaints that needs to be addressed.
Other informaon at the history taking that may prove useful
include:
Medical history: General paent management, prescribing any
medicaons Dental history: Anxiety, atudes to dental care Oral
hygiene and habits: Assess the paents oral health, parafunconal
habits is useful
informaon to the dierenal diagnoses.
Social history: Smoking and alcohol status, occupaonA full oral
examinaon is necessary if I am seeing the paent for the rst me.
This is necessary to
detect early if there is anything sinister the paent has not
already menoned. With the extra-oral
examinaon, I would be checking the head and neck for:
Symmetry: obvious swellings Abnormal changes in colour and
consistency of the skin e.g. redness if inammaon present Swellings
or lumps on palpaon Funcon of the temporomandibular joint: to
assess if trismus present or abnormal funcon
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Lip formIntra-orally, I would examine the so ssues which
includes the gingivae, oral mucosa, tongue, oor
of mouth, palate and tonsillar region for any abnormalies. I
would then focus on the general state
of the denon:
Condion of the natural teeth How much restorave work has been
done prior? Condion of the restorave work Is any wear signs
present? Physiological or pathological Presence of plaque and
calculus Presence of acve and arrested caries Periodontal status
Occlusion
When examining the suspect tooth (or suspect teeth if the paent
is unable to be locate one in
parcular), assessments I would make are:
Any obvious pathology present? E.g. caries, fracture, wear
facets into denne/pulp, Any restoraons present? If so, how large
and deep are these restoraons. Is there any
marginal leakage?
Periodontal support Mobility Is it in occlusion and if so, is it
taking more stress than the other teeth?
With these invesgaons so far, I am able to lter out my dierenal
diagnoses to the one or few
that remain. In order to further support the diagnosis or
invesgate the treatment opons, special
invesgaon tests can prove useful. These are not diagnosc on its
own. Special tests used
commonly in pracce are:
Radiographs: bitewings to assess any pathologies at the
interproximal areas, a periapical ofthe tooth or region in queson
may help to view the extent of pathology, if it involves the
periapical or marginal periodontal regions and bucco-palatal
fractures, quality of root
treatment if present.
Vitality tests of the pulp such as the electric pulp test, cold
test and hot test. These can bequite variable and one has to
consider that they are not enrely conclusive. A heavily
restored tooth with a sclerosed pulp chamber may give a negave
vitality even though vital
pulp ssue may be present in the canals. In contrast, it is
possible for a dead pulp to give a
posive reading due to uids in the canal.
Percussion and palpaon tests is useful to check if the
periodontal ligaments are inamed orin a fracture, painful due to
being stretched or broken.
Dyes such as methylene blue could be used to detect cracks and
non-displaced fractures.Once special tests have been performed, if
necessary, the correct diagnosis can be reached and the
appropriate management of the problem and be made. Other
necessary special tests can be made if
the aeology may be non-odonogenic in origin.
It is possible for a paent complaining of toothache to not
actually have a toothache per se. The
aeology of the pain may come from the pulp, periodontal
ligament, larger nerves (in the case of
neuralgia), referred pain from regional structures e.g. sinus,
and psychogenic. Thus my dierenal
diagnoses would be:
